PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $250 Individual $750 Individual $500 Family $1,500 Family All covered expenses accumulate simultaneously toward the preferred or non-preferred Deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services, as indicated in the plan, are excluded from charges to meet the Deductible. Pharmacy expenses do not apply towards the Deductible. The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Deductible amount. Member Coinsurance 10% 40% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family All covered expenses accumulate simultaneously toward the preferred or non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Pharmacy expenses apply towards the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, copays, and deductibles (except any penalty amounts) may be used to satisfy the Payment Limit. The family Payment Limit is a cumulative Payment Limit for all family members. The family Payment Limit can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Payment Limit amount. Lifetime Maximum Unlimited except where otherwise indicated. Payment for Non-Preferred Not Applicable Professional: 180% of Medicare Facility: 225% of Medicare *We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are "in network" or "out of network." We want to help you understand how much we will pay for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. As an example, you may choose a doctor in our network. You may choose to visit an out-of-network doctor. If you choose a doctor who is out of network, your health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, we will limit the amount it will pay. This limit is called the "recognized" or "allowed" amount. When you choose out-of-network care, we "recognize" an amount based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much we "recognize" depends on the plan you or your employer picks. Your out-of-network doctor sets the rate to charge you. It may be higher -- sometimes much higher -- than what your plan "recognizes" or "allows." Your doctor may bill you for the dollar amount that we don't recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or maximum out-of-pocket. To learn more about how we pay out-of-network benefits visit our website. You can avoid these extra costs by getting your care from our broad network of health care providers. This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan's copayments, coinsurance and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles.* Primary Care Physician Selection Optional Not Applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Prepared: 02/12/2015 07:07 PM Page 1
Referral Requirement None None PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 30%; 1 exam per calendar year up to age 65, 1 exam per calendar year age 65 and older Routine Well Child Exams/Immunizations Covered 100%; deductible waived Covered 100%; deductible waived 7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life, 3 exams 25-36 months, 1 exam per calendar year thereafter to age 22. Routine Gynecological Care Exams Covered 100%; deductible waived 30%; 2 exams per calendar year. Includes routine tests and related lab fees. Routine Mammograms Covered 100%; deductible waived 30%; Women's Health Covered 100%; deductible waived 30%; Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam Covered 100%; deductible waived 30%; Prostate-specific Antigen Test Covered 100%; deductible waived 30%; Colorectal Cancer Screening Covered 100%; deductible waived Covered under Routine Adult Exams Recommended: For all members age 50 and over. Routine Eye Exams Covered 100%; deductible waived 30%; 1 routine exam per 24 months. Routine Hearing Exams Covered 100%; deductible waived 30%; PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK Office Visits to PCP $20 copay; deductible waived 30%; Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $30 copay; deductible waived 30%; Pre-Natal Maternity Covered 100%; deductible waived Covered according to standard claim practice. E-visit to PCP $20 copay; deductible waived 30%; An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. E-visit to Specialist $30 copay; deductible waived 30%; An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through our authorized internet E-visit service vendor. Walk-in Clinics $20 copay; deductible waived 30%; Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Testing deductible waived Allergy Injections Prepared: 02/12/2015 07:07 PM Page 2
DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK Diagnostic X-ray 10%; 40%; If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Laboratory 10%; 40%; If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Outpatient Complex 10%; 40%; Imaging EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK Urgent Care Provider $75 copay; deductible waived 30%; Non-Urgent Use of Urgent Care Provider Emergency Room $100 copay; deductible waived Same as in-network care Copay waived if admitted Non-Emergency Care in an Emergency Room Emergency Use of Ambulance Covered 100%; Same as in-network care Non-Emergency Use of Ambulance HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK Inpatient Coverage 10%; 40%; Inpatient Maternity Coverage (includes delivery and postpartum care) 10%; 40%; Outpatient Hospital Expenses 10%; 40%; Outpatient Surgery 10%; 40%; Outpatient Surgery - Freestanding Facility 10%; 40%; MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient 10%; 40%; Outpatient $30 copay; deductible waived 30%; Crisis Intervention Services $30 copay; deductible waived 30%; ALCOHOL/DRUG ABUSE IN-NETWORK OUT-OF-NETWORK SERVICES Inpatient 10%; 40%; place of service where it is rendered Residential Treatment Facility 10%; 40%; Outpatient $30 copay; deductible waived 30%; OTHER SERVICES IN-NETWORK OUT-OF-NETWORK Convalescent Facility 10%; 40%; Limited to 60 days per calendar year. Prepared: 02/12/2015 07:07 PM Page 3
Home Health Care 25%; deductible waived 25%; deductible waived Limited to 40 visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 10%; 40%; Hospice Care - Outpatient 10%; 40%; Private Duty Nursing - Outpatient Outpatient Short-Term Rehabilitation $30 copay; deductible waived 30%; Includes Speech, Physical, and Occupational Therapy, limited to 30 visits per calendar year, unlimited for early intervention services from birth to age 3. Autism Behavioral Therapy $30 copay; deductible waived 30%; Covered same as any other Outpatient Mental Health benefit Autism Applied Behavior Analysis $30 copay; deductible waived 30%; Covered same as any other Outpatient Mental Health benefit with no visit limits or age restrictions up to 680 hours per a calendar year. Autism Physical Therapy $30 copay; deductible waived 30%; Autism Occupational Therapy $30 copay; deductible waived 30%; Autism Speech Therapy $30 copay; deductible waived 30%; Spinal Manipulation Therapy $30 copay; deductible waived 30%; Durable Medical Equipment 50%; 50%; Diabetic Supplies Covered same as PCP office visit cost sharing Covered same as any other medical expense. Fertility Drugs (oral and injectable) 10% 40%; Contraceptive drugs and devices Covered 100%; deductible waived Covered same as any other expense. not obtainable at a pharmacy Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Transplants 10%; 40%; Preferred coverage is provided at an IOE contracted facility only. Bariatric Surgery 10%; 40%; Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan. FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK Infertility Treatment place of service where it is rendered Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services place of service where it is rendered Coverage includes Artificial Insemination and Ovulation Induction. Non-Preferred coverage is provided at a Non-IOE facility. place of service where it is rendered Prepared: 02/12/2015 07:07 PM Page 4
Advanced Reproductive Technology (ART) ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Vasectomy. Tubal Ligation Covered 100%; deductible waived. PHARMACY IN-NETWORK OUT-OF-NETWORK Pharmacy Plan Type Aetna Premier Open Formulary Retail $10 copay for generic drugs, $20 copay for formulary brand-name drugs, and $35 copay for non-formulary brand-name drugs up to a 30 day supply at participating pharmacies. Mail Order $20 copay for generic drugs, $40 copay for formulary brand-name drugs, and $70 copay for non-formulary brand-name drugs up to a 31-90 day supply from Aetna Rx Home Delivery. Aetna Specialty CareRx $10 copay for generic drugs, $20 copay for formulary brand-name drugs, and $35 copay for non-formulary brand-name drugs. 20% of submitted cost after the applicable preferred copay Not Applicable Not Applicable Expanded Drug List First prescription fill at any retail drug facility. Subsequent fills must be through our preferred Aetna Specialty Pharmacy network. Choose Generics with Dispense as Written (DAW) override - The member pays the applicable copay only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan Includes: Diabetic supplies and medication covered at PCP cost sharing and Contraceptive drugs and devices obtainable from a pharmacy. Performance Enhancing Drugs limited to 4 tablets per month. Oral and injectable fertility drugs included (physician charges for injections are not covered under RX, medical coverage is limited). Premier Precert included with 90 day Transition of Care. Premier Step Therapy included with 90 day Transition of Care. Formulary Generic FDA-approved Women's Contraceptives and certain over-the-counter preventive medications covered 100% in network. GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 regardless of student status. Plans are provided by: Aetna Life Insurance Company. While this material is believed to be accurate as of the production date, it is subject to change. Prepared: 02/12/2015 07:07 PM Page 5
Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents. Cosmetic surgery, including breast reduction. Custodial care. Dental care and dental X-rays. Donor egg retrieval. Durable medical Equipment Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial. Hearing aids Home births Immunizations for travel or work, except where medically necessary or indicated. Implantable drugs and certain injectable drugs including injectable infertility drugs. Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents. Long-term rehabilitation therapy. Non-medically necessary services or supplies. Orthotics except diabetic orthotics. Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-the-counter medications (except as provided in a hospital) and supplies. Radial keratotomy or related procedures. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs. Special duty nursing. Therapy or rehabilitation other than those listed as covered. Treatment of behavioral disorders. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. Prepared: 02/12/2015 07:07 PM Page 6
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. Translation of the material into another language may be available. Please call Member Services at 1-888-982-3862. Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-982-3862. Plan features and availability may vary by location and group size. For more information about Aetna plans, refer to www.aetna.com. 2014 Aetna Inc. Prepared: 02/12/2015 07:07 PM Page 7